My Advance Care PlanMy Wishes and Preferences

My Advance Care Plan

WhatisthisPlanfor?ThePlancanhelpyouprepareforthefuture.Itgivesyouanopportunitytothinkabout,talkaboutandwritedownyourwishesandpreferencesforcareinthefutureandattheendofyourlife.ThePlancanhelpyouandyourcarers(yourfamily,friendsandprofessionals)tounderstandwhatisimportanttoyouwhenplanningyourcare.Ifatimecomeswhen,forwhateverreason,youareunabletomakeadecisionforyourself,anyonewhohastomakedecisionsaboutyourcareonyourbehalfwillhavetotakeintoaccountanythingyouhavewritteninyourPlan.Sometimespeoplewishtorefusespecificmedicaltreatments inadvance.ThisPlanisnotmeantto be used for such legally binding refusals. If you decide that youwant to refuse anymedicaltreatments, youmaydo sousingadocument calledan ‘AdvanceDecision toRefuseTreatment’whichyouwillneedtodiscusswithyourdoctors.Rememberthatyourviewsmaychangeovertime.Youcanchangewhatyouhavewrittenwheneveryouwishto,anditwouldbeadvisabletoreviewyourPlanregularlytomakesurethatitstillreflectswhatyouwant.

WhatshouldIincludeinmyPlan?Youshouldincludeanythingthatisimportanttoyouorthatyouareworriedabout.Itisagoodideatothinkaboutyourbeliefsandvalues,whatyouwouldandwouldnotlike,andwhereyouwouldliketobecaredforattheendofyourlife.

Willmywishesandpreferencesbemet?Whatyouhavewritten inyourPlanwillalwaysbe taken intoaccountwhenplanningyourcare.However, sometimes things can change unexpectedly (like carers becoming over-tired or ill), orresourcesmaynotbeavailable tomeetaparticularneedor thehealth condition thatyoumaydevelopandcouldmakeithardtofollowyourwishesentirely.

ShouldItalktootherpeopleaboutmyPlan?You may find it helpful to talk about your future care with your family and friends, althoughsometimesthiscanbedifficultbecauseitmightbeemotionalorpeoplemightnotagree.Itcanalsobeusefultotalkaboutanyparticularneedsyourfamilyorfriendsmayhaveiftheyaregoingtobeinvolvedincaringforyou.Yourprofessionalcarers(likeyourdoctor,nurseorsocialworker)canhelpandsupportyouandyourfamilywiththis.Whenyouhave completedyourPlanyouareencouraged tokeep itwithyouand share itwithanyoneinvolvedinyourcaree.g.yourGPandotherhealthandsocialcarestaffaswellasyourfamilyand/orthoseclosetoyou.Unlesspeopleknowwhatisimportanttoyou,theywillnotbeabletotakeyourwishesintoaccount.

My Advance Care Plan

Personalinformation

Name

Address

DOB

GPDetails

Nextofkin/Lastingpowerofattorney

Whowouldyouliketobeconsultedif iteverbecomesdifficultforyoutomakedecisionsorinthecaseofanemergency?

Ifyouhaveofficiallyappointedsomeonetomakedecisionsonyourbehalf,usingaLastingPowerofAttorney (LPA) for health and welfare, please indicate this below. This is different to a LPA forfinancialaffairs.

Name

Address

Tel.No

Relationship

DotheyhaveLPAforhealth&welfare?

Yes☐

No☐

Name

Address

Tel.No

Relationship

DotheyhaveLPAforhealth&welfare?

Yes☐

No☐

MylifestoryAbriefsummaryofimportantthingsyouwouldlikepeopletoknowaboutyou–family,home,placeswhere you have lived,working life, retirement, current and past interests. Youmay alsowish toattachacouplephotosofyourself,asyoulooknowandonefromyourpast.

ThepresentA brief description of your current situation, problems, difficulties or concerns (includinggenerallevelsofhealthandability).

MyfuturecareWherewouldyou like tobecared for if youbecomeunwellandunable to lookafteryourselfe.g.stay at home, move into sheltered or other supported accommodation (private flat with sharedfacilitiesandawarden),residentialcare(homefor long-termcare)ornursinghome(carehomewithnursingcare)?

Myfirstchoice:

Mysecondchoice:

Comments:

Whatareyourwishesandpreferencesforyourfuturecare?

Whatwould give you a good quality of life?What do you like?What are your hobbies andinterests?What’simportanttoyou?

What are your food/drink preferences, hygiene (bath/shower/shave/hair/make-up), sleep(preferredtimesforgettingup/goingtobed,lighton/off,windowopen/closed)?

Isthereanythingyouworryaboutorfearhappening?Doyouhaveconcernsaboutpracticalissues(whowilllookafteryourchild,pet…)?

Doyouhaveanythoughtsabouthowmuchactivetreatmentyouwouldwanttoreceiveatthisstage?

MyendoflifecareWhenyoureachtheendofyourlifewherewouldyouliketobecaredfore.g.athome,carehome,hospitalorhospice?

Myfirstchoice:

Mysecondchoice:

Comments:

Whatwouldbeimportanttoyouasyouapproachtheendofyourlifeanddoyouhaveanyspecificwishesforthistime?

Whowouldyouliketobewithyou?Howwouldyoulikethingstobe?

Isthereanythingyouworryaboutorfearhappening?

Isthereanythingthatmaycomfortyoue.g.music,smells,photos?

Whatareyourthoughtsaboutpaincontrol?

Doyouhaveanythoughtsaboutactivetreatmentatthisstage?

Pleasegivedetailsbelowofanypeopleyouwouldliketobecontactedattheendofyourlife,whocouldinformothersofyourdeathandpossiblyyourfuneralifyouarehavingone.

Name:

Relationship:

Telephone:

Address:

Name:

Relationship:

Telephone:

Address:

Name:

Relationship:

Telephone:

Address:

MyspiritualCare

Doyouhaveaparticularfaithorbeliefsystemthatisimportanttoyou?

Howwouldyoulikethistobetakenintoaccountattheendofyourlife?

Pleasegivedetailsbelowofanypeopleyouwouldliketobecontactedattheendofyourlife,whocouldinformothersofyourdeathandpossiblyyourfuneralifyouarehavingone.

Name:

Relationship:

Telephone:

Address:

Name:

Relationship:

Telephone:

Address:

Name:

Relationship:

Telephone:

Address:

MyspiritualCare

Doyouhaveaparticularfaithorbeliefsystemthatisimportanttoyou?

Howwouldyoulikethistobetakenintoaccountattheendofyourlife?

AdvancedecisionstorefusetreatmentHaveyoumadeanAdvanceDecision toRefuseTreatmentwithyourGP (previouslyknownasaLivingWillorAdvanceDirective)?

Yes☐ No☐

Ifyes,pleasegivedetailsofwherethisiskeptbelowandgiveacopytoyourhealthcareprofessionals:

Funeralwishes

Iwishtobe:Buried☐ Cremated☐

Haveyouapre-paidfuneralplan(tocoverthecostofyourfuneral)? Yes☐ No☐

Ifyes,pleasegivedetailsincludingproviderandpolicynumberandwherethesearekept:

Haveyourecordedyourfuneralwishes? Yes☐ No☐ Wishesyoumayhaveforyourfuneral:

Will

HaveyoumadeaWill? Yes☐ No☐ Ifyes,whereistheWillheld?

Organdonation

AreyouontheNHSOrgandonorregister?Yes☐ No☐Ifyes,pleaseaddyourNHSOrgandonornumber:_______________________________________

Comments:

Formoreinformationaboutorgandonationring03001232323orwww.organdonation.nhs.uk

For more information about donating your body to London medical and dental schools seewww.kcl.ac.uk/biohealth/study/departments/anatomy/lao/index.aspx

Furtherinformation

Doyouhaveanyfurthercommentsorwishesthatyouwouldliketosharewithothers?

Completion

Detailsofthepersoncompletingthisform:

Name:

Signature:

Date:

ReviewsItisadvisedthatyoureviewyourplanregularlyanddocumentanychangestoyourwishes.YoucanrecordanychangesintheAddendumsectionbelow.

Pleaseensurethisdocumentiseasilyaccessibletothosewhoneedtorefertoitandyouhavesharedyourwishes,preferencesandplanswiththoseimportanttoyou.

PleasealsoshareacopywithyourGPandanyotherhealthorsocialcareprofessionalinvolvedinyourcare,andyourfamilyand/orthoseclosetoyou.

AddendumPleaseusethisspacetorecordanychangestoyourPlan.RemembertosignanddatethesechangesandtosharethemwiththosewhoalreadyholdacopyofyourPlanaswellasyourGPandanyoneelseinvolvedinyourhealthandsocialcare.